Mortality and Morbidity After Open Surgical Lower Extremity Revascularization in Patients With Peripheral Artery Disease and Concurrent Abdominal Stoma.

OBJECTIVES: Patients with peripheral artery disease (PAD) often require treatment with open lower extremity revascularization (LER). Patients with PAD often have other comorbidities and associated conditions that affect procedural outcomes, including abdominal stomas. The aim of this work is to investigate the impact that stomas may have on postoperative outcomes and complications. METHODS: We performed a 5-year (2016-2020) analysis of the Nationwide Readmission Database. We identified all adult patients undergoing open LER. These patients were categorized into 2 groups: stoma and no-stoma. Propensity score matching (1:1) was used to control for demographics and comorbidities. Index admission outcomes and readmission rate were examined. RESULTS: 212,275 open LER patients were identified. A matched cohort of 3088 patients (1:1 stoma vs no-stoma) was obtained. Patients with stomas had higher rates of several postoperative complications: acute posthemorrhagic anemia (29.1%, P < 0.01), acute kidney injury (21.4%, P < 0.001), index sepsis (10.3%, P < 0.001), and index SSI (2.8%, P < 0.001). There were no significant statistical differences between the 2 groups for acute myocardial infarction. Those with stomas had worse outcomes: greater in-hospital mortality (4.7%, P < 0.05), length of stays (median 7 days, P < 0.001), total charges (median 108,037 dollars, P < 0.001), discharges to long-term care facilities (30.8%, P < 0.001), discharges to their own homes needing home health care (30.1%, P < 0.001), 30-day readmission rates (23.2%, P < 0.01), and 30-day readmission mortality (6.1%, P < 0.01). CONCLUSIONS: Concurrent abdominal stoma is associated with increased postoperative morbidity and mortality after open LER. Further prospective studies are needed to validate these results.

Racial, biological sex, and geographic disparities of venous thromboembolism in the United States, 2016 to 2019.

BACKGROUND: Venous thromboembolism (VTE) stands as the leading cause of preventable death within hospitals in the United States. Although there have been some studies investigating the incidence rates of VTE, there has yet to be a large-scale study elucidating disparities in sex, race, income, region, and seasons in patients with VTE. The goal of this study was to report the disparities in race, sex, income, region, and seasons in patients with VTE, pulmonary embolism (PE), and deep vein thrombosis (DVT), in hospitalized patients from 2016 to 2019. METHODS: We used the United States National Inpatients Sample database to identify inpatients diagnosed with PE, DVT, and PE and DVT from 2016 to 2019. The inpatient incidence per thousand was calculated for sex and race using the weighted sample model. The regional and monthly incidence of DVT and PE per thousand inpatients and risk of incidence were calculated. Patients' characteristics including hospital type, bed size, median length of stay, median total charges, and mortality were also collected. RESULTS: We examined 455,111 cases of VTE, 177,410 cases of DVT, 189,271 cases of PE, and 88,430 cases of both DVT and PE combined. Over the study period, we observed a statistically significant trend among PE hospitalization incidences. There was a strong and positive correlation between DVT and PE inpatients. Black inpatients had the highest cumulative incidence of hospitalizations in all cohorts with 10.36 per 1000 in PE and 9.1 per 1000 in DVT. Asian and Pacific Islander inpatients had the lowest cumulative incidence with 4.42 per 1000 in PE and 4.28 per 1000 in DVT. Females showed the lowest cumulative incidence with 7.47 per 1000 in PE and 6.53 per 1000 in DVT. The Mountain region was the highest among PE hospitalizations with 9.62 per 1000. For DVT, the Middle Atlantic region was the highest at 8.65 per 1000. The in-hospital mortality rate was the highest among the PE hospitalizations at 7.3%. Also, the trend analysis showed significant increases among all groups. CONCLUSIONS: Over the study period (2016-2019), we report the racial, biological sex, and geographical disparities from the National Inpatient Sample database, highlighting that Black inpatients had the highest incidence of PE and DVT, whereas Asian/Pacific Islander inpatients had the lowest incidences of PE and DVT. Moreover, women had a lower incidence compared with men. The observed regional variations indicated that the incidence of PE was highest in the Mountain region, whereas the incidence of DVT was lowest in the Middle Atlantic region. There was an increase in the mortality of inpatients diagnosed with VTE reflecting the growing burden of this condition in the US health care system.

Inpatient peritoneal dialysis catheters placed across the United States during a 3-year period: Lessons learned from 15,000 patients.

BACKGROUND: Peritoneal dialysis is a popular option for patients with end-stage renal disease. A recent presidential executive order has incentivized in-home end-stage renal disease treatments, leading to an increase in peritoneal dialysis use. Guidelines exist for creating and maintaining peritoneal dialysis access without addressing the optimal technique. This study evaluates nationwide peritoneal dialysis catheter placement practices and their long-term outcomes. METHODS: Retrospective cohort analysis of Nationwide Readmission Database from 2017 to 2019. Patients with end-stage renal disease undergoing inpatient peritoneal dialysis catheter placement were included. Six-month readmissions, mortality, and peritoneal dialysis catheter-specific outcome measures were assessed among survivors of admission, including catheter leakage, mechanical breakdown, displacement, revision or replacement, removal, exit site infections, intra-abdominal abscess, and sepsis. Binary logistic regression analyses were performed. RESULTS: In the study, 14,863 patients with inpatient peritoneal dialysis catheter insertions were identified, of which 7,096 were analyzed (4,150 [59%] laparoscopic, 1,781 [25%] fluoroscopic, 1,165 [16%] open), 847 (12%) had major complications, 931 (13%) were readmitted, and 102 (1.4%) died within 6 months. Univariate analyses demonstrated that laparoscopy had higher mechanical complications, exit-site infections, catheter revision, and removal within 6 months, and fluoroscopy had higher sepsis and mortality. Multivariate analyses showed fluoroscopy was associated with intraabdominal abscess (adjusted odds ratio, 2.36; P = .025), laparoscopy with exit-site infections (adjusted odds ratio, 0.49; P = .005), and open surgery with catheter displacement (adjust odds ratio, 2.95; P = .021). CONCLUSION: This is the first large-scale study on inpatient peritoneal dialysis catheter placement outcomes in the United States. Fluoroscopic and open surgical placements are routinely performed, but laparoscopy remains the mainstay with fewer exit-site infections. Overall, peritoneal dialysis is a safe option, with 1 in 9 patients having an infectious or mechanical complication within 6 months. Furthermore, large-scale prospective studies are warranted to identify the optimal placement technique.

Gender, BMI, Patient Comorbidities, and Hospital Characteristics Influence 30-Day Readmission Following Vertical Sleeve Gastrectomy.

PURPOSE: Obesity impacts 300 million people worldwide and the number continues to increase. Laparoscopic sleeve gastrectomy (LSG) is one of several bariatric procedures offered to help these individuals achieve a healthier life. Here, we report 30-day readmission rates and risk factors for readmission after gastrectomy. MATERIALS AND METHODS: We used the US Healthcare Utilization Project's Nationwide Readmission Database (NRD) from 2016 to 2019 for patients who underwent laparoscopic gastrectomy and evaluated 30-day readmission rates, comparing readmitted patients to non-readmitted patients. Confounder adjusted and unadjusted analysis were proceeded to the potential factors. RESULTS: The study population consisted of 235,563 patients, with a 3.0% readmission rate. Factors associated with a higher readmission rate included older age, male gender, higher BMI, Medicare as the primary payer, longer length of stay, higher total charge, higher Charlson Comorbidity Index, higher Elixhauser-Comorbidity Index, lower household income, non-elective admission type, and non-routine disposition. Additionally, larger hospital bed size, and private, invest-own hospital ownership were associated with higher readmission rates. After adjusting for confounders, several comorbidities and complications were found to be significantly associated with readmission, including ileus, abnormal weight loss, postprocedural complications of digestive system, acute posthemorrhagic anemia, and history of pulmonary embolism (all p < 0.001). CONCLUSIONS: Patient characteristics including age, BMI, and payment source, as well as hospital characteristics, can impact the 30-day readmission after LSG. Such factors should be considered by CMS when deciding on penalties related to readmission.

Mortality and morbidity following initiation of anticoagulant or antiplatelet treatment for blunt cerebrovascular injury.

OBJECTIVE: Cerebrovascular accidents (CVA) are potential sequelae of blunt cerebrovascular injuries (BCVI). To minimize their risk, medical therapy is used commonly. It is unclear if anticoagulant or antiplatelet medications are superior for decreasing CVA risk. It is also unclear as to which confer fewer undesirable side effects specifically in patients with BCVI. The aim of this study was to compare outcomes between nonsurgical patients with BCVI with hospital admission records who were treated with anticoagulant medications and those who were treated with antiplatelet medications. METHODS: We performed a 5-year (2016-2020) analysis of the Nationwide Readmission Database. We identified all adult trauma patients who were diagnosed with BCVI and treated with either anticoagulant or antiplatelet agents. Patients who were diagnosed with index admission CVA, intracranial injury, hypercoagulable states, atrial fibrillation, and or moderate to severe liver disease were excluded. Those who underwent vascular procedures (open and/or endovascular approaches) and or neurosurgical treatment were also excluded. Propensity score matching (1:2 ratio) was performed to control for demographics, injury parameters, and comorbidities. Index admission and 6-month readmission outcomes were examined. RESULTS: We identified 2133 patients with BCVI who were treated with medical therapy; 1091 patients remained after applying the exclusion criteria. A matched cohort of 461 patients (anticoagulant, 159; antiplatelet, 302) was obtained. The median patient age was 72 years (interquartile range [IQR], 56-82 years), 46.2% of patients were female, falls were the mechanism of injury in 57.2% of cases, and the median New Injury Severity Scale score was 21 (IQR, 9-34). Index outcomes with respect to (1) anticoagulant treatments followed by (2) antiplatelet treatments and (3) P values are as follows: mortality (1.3%, 2.6%, 0.51), median length of stay (6 days, 5 days; P < .001), and median total charge (109,736 USD, 80,280 USD, 0.12). The 6-month readmission outcomes are as follows: readmission (25.8%, 16.2%, <0.05), mortality (4.4%, 4.6%, 0.91), ischemic CVA (4.9%, 4.1%, P = not significant [NS]), gastrointestinal hemorrhage (4.9%, 10.2%, 0.45), hemorrhagic CVA (0%, 0.41%, P = NS), and blood loss anemia (19.5%, 12.2%, P = NS). CONCLUSIONS: Anticoagulants are associated with a significantly increased readmission rate within 6 months. Neither medical therapy is superior to one another in the reduction of the following: index mortality, 6-month mortality, and 6-month readmission with CVA. Notably, antiplatelet agents seem to be associated with increased hemorrhagic CVA and gastrointestinal hemorrhage on readmission, although neither association is statistically significant. Still, these associations underscore the need for further prospective studies of large sample sizes to investigate the optimal medical therapy for nonsurgical patients with BCVI with hospital admission records.

Risk factors for readmission after open abdominal aortic aneurysms repair and its outcome in chronic kidney disease patients.

OBJECTIVE: Readmission after vascular procedures is a burden to hospitals and the Medicare system. Therefore, identifying risk factors leading to readmission is vital. We examined the frequency of and risk factors for 30-day readmission after open aneurysm repair (OAR) and explored post-operative outcomes with special attention for those with preexisting chronic kidney disease (CKD). METHODS: Patients who underwent OAR were identified in the National Readmission Database (2016-2018). Demographic information and comorbidities were collected. Patients readmitted within 30 days after their index hospitalization were identified and compared to patients without readmission records. RESULTS: A total of 5090 patients underwent OAR during the study timeframe with 488 patients (9.6%) were readmitted within 30 days. Females were more readmitted than males (F = 11.1% vs M = 9.0%, P < 0.001). Readmitted patients had more comorbidities (median ECI 12, P < 0.05), were on Medicare (73.7%, P < 0.001), had higher surgery admission cost ($146,844, P < 0.001), longer length of stay (8 days, P < 0.001), and were discharged to a lower level care facility (62.7%, P < 0.001). Comorbidities that predisposed patients for readmission include: peripheral arterial disease (OR 2.15, P < 0.01), asthma (OR 1.87, P < 0.01), chronic heart failure (OR 1.74, P < 0.05). On readmission visit, acute renal failure (23.8%) was the most common diagnosis, while intestinal surgery (13.7%) was the most common procedure. Patients with CKD (n = 968, 18.9% of total population) had double the mortality rate compared to non-CKD patients on surgery admission (10.4%, P < 0.001) and readmission (10.1%, P < 0.001). CONCLUSION: Certain factors were noted to increase readmission rate, special attention need to be paid when dealing with such group of patients requiring OAR. Vascular surgeons should meticulously weigh benefits and risks when considering OAR in patients with CKD who are not a candidate for endovascular repair, and optimize their kidney function before considering such approach.

The relationship between lower extremity amputation and body mass index.

OBJECTIVES: Non-traumatic lower extremity amputation (LEA) is associated with significant morbidity and mortality. Diabetes mellitus (DM) and peripheral vascular disease (PVD) are associated with increased risk for LEA. As such, DM and PVD account for 54% of all LEA's, performed in the United States annually. As obesity is highly associated with both DM and PVD, our study sought to explore the relationship between LEA and obesity defined by BMI. METHODS: Using the National Inpatient Sample (NIS) database, a retrospective review of patients who underwent non-traumatic LEA (LEA) between 2008 and 2014 was performed. The International Classification of Diseases 9th edition (ICD-9) codes were utilized to determine the diagnoses, comorbidities, and procedures. Patient BMIs were classified as follows: Non-obese [BMI <30], Obesity class I [BMI 30-34.9], Obesity class II [BMI 35-39.9], and Obesity class III [BMI ≥40]. Predictors for LEA were compared between groups using chi-square test and binary logistic regression to identify possible underlying factors associated with LEA. We also conducted a multivariate analysis to measure the effect of multiple variables on LEA. RESULTS: We identified 16,259 patients with non-traumatic LEA and a mean age of 59.9 years. Rate of amputation in females was lower than males at 0.35% vs 0.87% respectively (p < 0.001). Of patients that underwent amputation there was a V-shape trend based on BMI, with 30.4% in non-obese patients, 18.2% in obesity class I, 17.3% in obesity class II, and 34.1% in obesity class III. The incidence of diabetes increased with obesity class, while the incidence of PVD decreased. Interestingly, of those with DM there was an inverse relationship between amputation rate and BMI class, with LEA rates in non-obese versus obesity class III patients were 1.63% vs 0.98% respectively (p < 0.001). Similarly, patients who had both diabetes and PVD showed a downward trend in LEA rate as obesity class increased; non-obese patients had a LEA rate of 8.01%, while obesity class III had 4.65% (p < 0.001). Patients in higher income bracket have lower odds of LEA (OR 0.77, p < 0.001) compared to the lowest income patients. Also, patients with comorbidities such as PVD (OR 10.78), diabetes (OR 5.02), renal failure (OR 1.41), and hypertension (OR 1.36) had higher odds to get an LEA (p < 0.001). Individuals with obesity class III are almost at half the odds (OR 0.52) to get an LEA compared to non-obese (p < 0.001). CONCLUSIONS: Higher BMI and female gender are protective factors against lower extremity amputation. Factors that predisposing to LEA include lower household income and certain comorbidities such as PVD, diabetes, renal failure, and hypertension. These findings warrant further research to identify patients at high risk for LEA and help develop management guidelines for targeted populations.

A Machine Learning Model for Prediction of Amputation in Diabetics.

BACKGROUND: Diabetic foot ulcer (DFU) and the resulting lower extremity amputation are associated with a poor survival prognosis. The objective of this study is to generate a model for predicting the probability of major amputation in hospitalized patients with DFU. METHODS: The National Inpatient Sample (NIS) database from 2008 to 2014 was used to select patients with DFU, who were then further divided by major amputation status. International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) and Agency for Healthcare Research and Quality (AHRQ) comorbidity codes were used to compare patient characteristics. For the descriptive statistics, the Student t test, the χ2 test, and the Spearman correlation were utilized. The five most predictive variables were identified. A decision tree model (CTREE) based on conditional inference framework algorithm and a random forest model were used to develop the algorithm. RESULTS: A total of 326 853 inpatients with DFU were identified, and 5.9% underwent major amputation. The top five contributory variables (all with P < .001) were gangrene (odds ratio [OR] = 11.8, 95% confidence interval [CI] = 11.5-12.2), peripheral vascular disease (OR = 2.9, 95% CI = 2.8-3.0), weight loss (OR = 2.6, 95% CI = 2.5-2.8), systemic infection (OR = 2.5, 95% CI = 2.4-2.53), and osteomyelitis (OR = 1.7, 95% CI = 1.6-1.73). The model performance of the training data was 77.7% (76.1% sensitivity and 79.3% specificity) and of the testing data was 77.8% (76.2% sensitivity and 79.4% specificity). The model was further validated with boosting and random forest models which demonstrated similar performance and area under the curve (AUC) (0.84, 95% CI = 0.83-0.85). CONCLUSION: Utilizing machine learning methods, we have developed a clinical algorithm that predicts the risk of major lower extremity amputation for inpatients with diabetes with 77.8% accuracy.

Nonhealing venous ulcer in a patient with dystrophic soft tissue calcification.

Venous leg ulcers (VLUs) are lesions of the skin found in regions of venous hypertension. VLUs that fail to heal can become chronic, especially because of calcified deposits in the bed of the ulcer. The unclear mechanism behind the cause of calcification poses a challenge when approaching diagnosis and management. In the present report, we discuss the case of a 58-year-old woman who had presented with a chronic VLU that was resistant to healing despite numerous interventions. During a 3-year period, a multidisciplinary team was involved to provide medical and surgical care. Eventually, she was found to have dystrophic calcification of the VLU.

A comparison of revascularization methods for peripheral arterial disease in diabetics: Changing trends in lower extremity revascularization from 2008 to 2014.

OBJECTIVES: This study examined the current demographic and outcome trends regarding endovascular and open revascularization for people with diabetes. METHODS: The National Inpatient Sample database was utilized to identify diabetic patients who underwent lower extremity revascularization and amputation procedures between 2008 and 2014. International Classification of Diseases 9th edition codes were used to identify the procedures, diagnoses, and comorbidities. RESULTS: We identified 38,143 diabetic patients who underwent endovascular revascularization and 25,415 who underwent open revascularization between 2008 and 2014. The number of endovascular and open revascularization procedures decreased steadily by 17.5% and 12.43% during the study period, respectively. The total charges for the endovascular procedure were greater than the open procedure ($98,761 vs. $80,782, p ≤ 0.001) despite similar median length of stay (5 days (inner quartile range (IQR) = 1-10) vs. 5 days (IQR = 3-10), p ≤ 0.001). Compared to open, the in-patient amputation rate for endovascular patients has been increasing faster for both minor (11.75% vs. 0.37%) and major amputations (3.08% vs. 0.19%). Although the post-procedure amputation rates between endovascular and open procedures were increased for endovascular patients (odds ratio [OR] = 1.71, confidence interval [CI] = 1.35-2.18, p ≤ 0.001) in 2008, by 2014 the risk of major amputation was doubled in endovascular patients (OR = 2.88, CI = 2.27-3.64, p ≤ 0.001). African Americans were more likely to undergo minor amputation than Whites (p ≤ 0.001). Lastly, diabetic patients with uncontrolled diabetes, systemic infection, weight loss, congestive heart failure, gangrene, and end-stage renal disease were more likely to undergo endovascular repair. CONCLUSIONS: As more medically complex patients undergo endovascular revascularization, endovascular revascularization for diabetic patients is becoming associated with higher total cost despite similar length of stay, minor amputation, and major amputation rates. Further studies are needed to continuously evaluate the post-procedural outcomes and cost effectiveness of this trend.

Machine learning prediction of diabetic foot ulcers in the inpatient population.

BACKGROUND: The objective of this study was to create an algorithm that could predict diabetic foot ulcer (DFU) incidence in the in-patient population. MATERIALS AND METHODS: The Nationwide Inpatient Sample datasets were examined from 2008 to 2014. The International Classification of Diseases 9th Edition Clinical Modification (ICD-9-CM) and the Agency for Healthcare Research and Quality comorbidity codes were used to assist in the data collection. Chi-square testing was conducted, using variables that positively correlated with DFUs. For descriptive statistics, the Student T-test, Wilcoxon rank sum test, and chi-square test were used. There were six predictive variables that were identified. A decision tree model CTREE was utilized to help develop an algorithm. RESULTS: 326,853 patients were noted to have DFU. The major variables that contributed to this diagnosis (both with p < 0.001) were cellulitis (OR 63.87, 95% CI [63.87-64.49]) and Charcot joint (OR 25.64, 95% CI [25.09-26.20]). The model performance of the six-variable testing data was 79.5% (80.6% sensitivity and 78.3% specificity). The area under the curve (AUC) for the 6-variable model was 0.88. CONCLUSION: We developed an algorithm with a 79.8% accuracy that could predict the likelihood of developing a DFU.

Disseminated Lomentospora prolificans infection presenting with arterial exsanguination.

Lomentospora prolificans is an opportunistic fungal pathogen found especially in Australia, Spain, Portugal, California, and the southern United States. Although it causes a wide spectrum of infections, disseminated L. prolificans infection remains very rare. The diagnosis and medical management are challenging. No clear guidelines are available for management. The treatment options are limited and mortality is high, especially for immunocompromised patients. In the present case report, we have highlighted the rare vascular effect of disseminated L. prolificans infection. We have reported the case of a 48-year-old immunocompromised man who had presented with a right groin mass. After extensive workup, the patient was found to have disseminated L. prolificans infection causing a superficial femoral artery pseudoaneurysm. A multidisciplinary team was involved to provide medical and surgical care. However, the patient died after treatment failure and withdrawal of support.

Unusual presentation of right-sided May-Thurner syndrome.

May-Thurner syndrome commonly presents with left leg swelling. Right-sided venous compression syndromes are rare. We report a 49-year-old gentleman who presented with right lower extremity swelling after leg trauma. He was found to have right distal common iliac vein compression by the overlying right internal iliac artery. He was treated with an endovascular approach with balloon venoplasty and stenting. This is a unique presentation of May-Thurner syndrome variation affecting the right lower extremity with limited description in the literature.

Evaluation of Current Pressure Ulcer Staging.

BACKGROUND: We sought to assess health professionals' satisfaction with the National Pressure Injury Advisory Panel staging system (NPUAP). METHODS: A paper survey assessing the satisfaction with the NPUAP was distributed to participants of a national wound care meeting. A total of 88 surveys were completed. Results were tabulated using SPSS. RESULTS: The survey response rate was 50%. Nearly all respondents (95.0%) used NPAUP for documentation. 75.3% indicated that a better staging system was needed. When participants were asked to evaluate their current staging system, 63.5% stated that the system does not adequately reflect patient's clinical condition, 61.6% felt that the current staging system was not easily reproducible, 58.0% believed that the current staging system was generally easy-to-use, and 43.9% indicated that it is unable to suggest management recommendations. When asked about an ideal classification system, the respondents proposed incorporating tissue necrosis (97.6%), depth of tissue involvement (96.3%), discharge documentation (92.5%), presence of osteomyelitis (90%), local infection (88.8%), and systemic infection (80.0%). Overall, 67.0% of the participants wanted to use a classification system that would reflect the progress of injury healing and could be used to indicate the need for intervention. DISCUSSION: Health care workers caring for pressure injury patients indicated dissatisfaction with the NPAUP.

Rankings From US News and World Report Have Minimal Correlation With Kidney and Liver Transplant Recipient Survival Results From Retrospective Data.

OBJECTIVES: Increased demand for quality health care has led to lay-press ranking systems, such as the ranking from US News and World Report (US News). Their "Best Hospitals" publication advertises itself as the go-to resource for patients seeking care in a number of specialty areas. We sought to test the relationship between US News rankings and transplant outcomes. MATERIALS AND METHODS: Using data from 2014 to 2018, we compared outcomes from the Scientific Registry of Transplant Recipients database for liver and kidney transplants against US News-ranked centers using the categories "Nephrology" and "GI Surgery and Gastroenterology" as substitutes, as US News does not rank transplant centers specifically. P < .05 was set as significant. RESULTS: Using hazard ratio data, we found that kidney transplant center rank had only a small impact on postoperative outcomes in terms of patient survival (hazard ratio = 0.996, P = .049) but had no impact on graft survival (hazard ratio = 0.997, P = .077). In addition, liver transplant center rank had no impact on liver graft survival (hazard ratio = 1.003, P = .304). The impact of hospital ranking on survival was minimal compared with other variables. CONCLUSIONS: The US News rankings for "Nephrology" and "GI Surgery and Gastroenterology" have minimal values as a measure of liver and kidney transplant outcomes, highlighting that these lay press rankings are not useful to the unique transplant patient population and that providers should help guide patients to transplant-specific resources.

Development and evolution of a robotic surgical technique for the treatment of thoracic outlet syndrome.

OBJECTIVE: We describe the development and evolution of a surgical technique that uses the robotic da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif) for the transaxillary approach to repair the disabling thoracic outlet syndrome (TOS). We report our patient outcomes associated with the use of this robotic technique. METHODS: We present a retrospective review and analysis of data collected from a 16-year experience of a single surgeon using a robotic surgical system and technique for TOS surgery. From the initial design of an endoscope attached to a microvideo camera in 1982 to the adoption of the monorobotic arm with integrated voice in 1998, the main objective of the transaxillary approach has always been to improve visualization of congenital cervical anomalies of the scalene muscles. From February 2003 to December 2018, we performed 412 transaxillary decompression procedures using the robotic da Vinci Surgical System. The surgical procedure has been described in further detail and includes the following steps: (1) positioning of the patient into a lateral decubitus position and using a monoarm retractor; (2) creation of a mini-incision in the axillary area and creation and maintenance of the subpectoral anatomic working space; (3) placement of endoscopic ports and engagement of the robotic instrumentation; (4) dissection of extrapleural and intrapleural soft tissue; (5) creation of the "floater" first rib; (6) excision of the cervical bands and first rib; and (7) placement of thoracostomy tubes for drainage and closure of the incisions. RESULTS: None of the patients died, and no patient experienced permanent neurovascular damage of the extremity. Of the 306 patients, 22 (5% of 441 operations) experienced complications. One patient developed postoperative scarring that required a redo operation with a robotic-assisted transaxillary approach. CONCLUSIONS: With its three-dimensional visual magnification of the anatomic area, the endoscopic robotic-assisted transaxillary approach offers safe and effective management of disabling TOS symptoms. The endoscope facilitates observation of the cervical bands and the mechanism (pathogenesis) of the neurovascular compression that causes TOS, thereby allowing complete excision of the first rib, cervical bands, and scalene muscle. We sought to develop and perfect this robotic approach. The present study was not intended to be a comparative study to nonrobotic TOS surgery.

Renal Transplant Patients Undergo Abdominal Aortic Aneurysm Repair at a Younger Age and Experience More Complications: Review of the Healthcare Cost and Utilization Project Database.

OBJECTIVE: The objective of this study was to determine whether history of kidney transplant is a risk factor for increased complications in patients who undergo abdominal aortic aneurysm (AAA) repair. BACKGROUND: The incidence of renal failure and subsequent kidney transplant is steadily rising. Many risk factors leading to AAA overlap with those of renal disease. Due to these similarities, a rising incidence of kidney transplant patients undergoing AAA repair is expected. We surmised a notable difference in AAA surgical repair outcomes in renal transplant recipients compared to the general population. METHODS: A retrospective analysis was performed on 59,836 adult patients with history of AAA repair and kidney transplant from 2008 to 2015. Data were obtained from the Nationwide Inpatient Sample database developed for the Healthcare Cost and Utilization Project. RESULTS: Significant differences in age, race, hospital characteristics, and complications were identified. The results suggest that patients with prior transplant generally have AAA repair at a significantly younger age (P < .001). A difference in race (P = .017), with 75% vs 87.4% non-Hispanic whites and 5% vs 1.5% Asian/Pacific Islander in the transplant and nontransplant groups, respectively, was shown. Procedures at transplant centers had significantly longer lengths of stay (P < .001) and higher total charges (P < .001). In addition, transplant recipients exhibited a higher in-hospital mortality index (P < .001) than the nontransplanted population. CONCLUSION: A history of kidney transplant significantly influences multiple aspects of care and complications regarding future AAA repair and is associated with increased in-hospital mortality index. Significant findings include increased total charges, longer lengths of stay, postoperative complications, and differences in age and race.

Robotic versus Laparoscopic Sigmoid Colectomy: Analysis of Healthcare Cost and Utilization Project Database.

Minimally invasive sigmoid colectomy via the laparoscopic approach (LA) has numerous benefits. We seek to compare outcomes between laparoscopic and robotic sigmoid colectomies. We analyzed the data using the National Inpatient Sample database between 2008 and 2014. Utilization and outcome measures were compared. The seven-year average number of patients who underwent elective sigmoid colectomy in the United States from 2008 to 2014 was estimated to be 197,053. Of these, 95.1 per cent were conducted using the LA. The mean age was 58.33 + 13.6 years and 58.23 + 12.8 years in laparoscopic and robotic approaches, respectively. No significant differences existed in respect to morbidities. Postoperative complications were comparable with respect to other complications. Length of hospital stay was statistically significantly shorter in the robot-assisted approach compared with the LA (mean 4.8 + 4 vs 5.7 + 5 days, respectively, P < 0.001). Patients who underwent robotic surgery had significantly higher total hospital charges than those who underwent laparoscopic surgery (median $45,057 vs $57,871 USD, P < 0.001). The advent of robot-assisted surgery has provided more options for patients and surgeons. Compared with laparoscopy, robot-assisted sigmoid colectomy has no clinical advantages in morbidity and mortality. However, the robotic approach has a significantly higher total charge to the patient.

Burn patients with history of kidney transplant experience increased incidence of wound infection.

OBJECTIVE: To determine if history of kidney transplant is an independent risk factor for increased incidence of wound infection and other morbidities in burn patients. BACKGROUND: While the goal of immunosuppression post-organ transplantation is to prevent graft rejection, it is often associated with significant adverse effects such as increased susceptibility to infection, drug toxicity, and malignancy. Burn injuries lead to a dysregulated hypermetabolic state and a compromised cutaneous barrier, which predisposes to infection and delayed wound healing. We surmise that a history of kidney transplant increases the risk of wound infection in in-hospital burn victims. METHODS: A retrospective analysis was performed on 57,948 adults diagnosed in-hospital with a burn injury between 2008-2014, obtained from the Nationwide Inpatient Sample (NIS) by Healthcare Cost and Utilization Project (HCUP). RESULTS: 103 burn victims (0.2%) with a history of kidney transplant (KTX) were identified. Compared to burn patients without a history of transplant (No-KTX), they were older (54.3 ± 13.8 vs 49.8 ± 18.7; p = 0.001), more likely be insured under Medicare (69.9% vs 31.1%; p < 0.001), and less likely to have Medicaid (5.8% vs 17.2%; p = 0.002). Higher in-hospital mortality index scores were observed in KTX compared to no-KTX with p < 0.001. The incidence rates of complications such as wound infection (33.0 vs 16.3; p < 0.001) and acute renal failure (18.4 vs 7.7; p < 0.001) were significantly higher in the KTX group. After adjusting for confounding factors in multivariable analysis, the incidence of wound infection remained significantly higher. Burn patients with history of KTX were not more likely to be treated at a transplant (TX) center. TX centers were determined to have higher mortality rate, longer length of stay, and higher total hospital charges. CONCLUSION: History of kidney transplant is an independent risk factor for increased incidence of wound infection in burn patients.

Catheter Directed Lysis and Thrombectomy Are Equally Effective for Extensive Deep Vein Thrombosis.

BACKGROUND: There is currently little consensus on the role of thrombectomy compared with catheter-directed lysis (CDL) for acute, extensive, proximal deep vein thrombosis (DVT). We sought to determine whether any differences in outcomes exist between thrombectomy and CDL in terms of postoperative venous patency, pulmonary emboli (PE), and bleeding/hematoma. METHODS: In an institutional review board-approved retrospective cohort study, patients from a single academic medical center with confirmed lower extremity DVT were divided into thrombectomy and CDL cohorts. Demographic information, comorbidities and laboratory data, postoperative patency, postoperative bleeding, postoperative PE, popliteal hematoma, and recurrence of DVT were collected. Type I error level was set at 0.05. RESULTS: Eighty-seven patients were identified, 51.7% received CDL, and 48.3% underwent thrombectomy. Patient comorbidities and hypercoagulable states were not significantly different among the groups. The two techniques did not have significantly different postoperative patency (P = 0.472), bleeding (P = 0.598), PE (P = 0.868), popliteal hematoma (P = 0.331), or recurrence of DVT (P = 0.835). CONCLUSIONS: In selecting optimum treatment for acute, extensive, proximal DVT, our retrospective cohort study found no significant differences among treatment groups in safety, efficacy, recurrence, and progression to PE. We conclude that modality of treatment should be decided based on hospital resources, surgeon experience, and comfort with each technique, patient's physiologic status, and associated costs.